Management of bleeding esophageal varices due to portal hypertension has traditionally relied on endoscopic sclerotherapy and operative intervention with placement of a portosystemic shunt. Although percutaneous decompression of portal hypertension was investigated 25 years ago, it was not clinically feasible until recently. With the advent of intravascular stents, the technique of creating a transjugular intrahepatic portosystemic shunt (TIPS) can now be effectively applied to treat the complications of portal hypertension, including variceal hemorrhage and refractory ascites. Since its introduction in 1989, TIPS has enjoyed widespread clinical application. The initial results with this procedure are encouraging and suggest that it is an effective means of reducing the frequency of variceal hemorrhage in patients with portal hypertension. The long-term patency rate and frequency of complications, however, have not been clearly defined. Similarly, the role of TIPS in the treatment of refractory ascites, Budd-Chiari syndrome, and hepatorenal syndrome remains unclear because sufficient data do not yet exist to support its general use in these settings.